Definition of staphyloma: It is the loss of microvasculature in the villi matrix, resulting in the accumulation of fluid in the villi matrix and the formation of vesicles of unequal size, resembling grapes, hence the name hydatidiform
mole). The majority of cases are complete. The clinical diagnosis of staph refers to complete staph, while partial staph with placental tissue or fetus is called partial staph. In spontaneous abortions, blister-like degeneration is found in 40% of patients, but it is not diagnosed as staphyloma.
Amenorrhea: Because gravida occurs in the trophoblastic layer of the pregnant egg, there is mostly amenorrhea for 2 to 3 months or longer.
Vaginal bleeding: This is a serious symptom and is a sign of spontaneous abortion of the gravida. It usually starts 2 to 3 months after amenorrhea and is mostly intermittent with a small amount of bleeding, but it can be interrupted by repeated heavy bleeding and, if examined carefully, sometimes blister-like material can be found in the bleeding. The vaginal bleeding apparently comes from the uterus and, in addition to flowing from the vagina, partially accumulates in the uterus; it may also accumulate completely in the uterus for a while, thus prolonging the amenorrhea.
Uterine enlargement: Most patients have a uterus larger than that of the corresponding month of menopause of pregnancy, and many of them come to the clinic because of a palpable lower abdominal mass (distended uterus or flavin cyst), but there are a few uteruses and menopause months in line with or even smaller than the month of menopause of the same, there may be two cases.
1, for the chorionic vesicles to regress to an atrophic state and stop developing, forming an auditory gravidity.
2. Some of the blistered fetal masses have been expelled, causing the uterine body to shrink and forming an incomplete abortion of the gravida.
Abdominal pain: distension and pain due to rapid enlargement of the uterus, or intrauterine bleeding, stimulating uterine contraction and pain, which can be mild or severe.
Pregnancy toxicity symptoms: about half of the patients may develop severe vomiting after menopause, and at a later stage, hypertension, swelling and proteinuria. No fetus is available and around 8 weeks of amenorrhea, ultrasound monitoring, no fetal sac, fetal heart and fetus are found. The fetal movement is still not felt and the fetal heart cannot be heard at gestational weeks, even at 18 weeks. ultrasound scan shows snow-like images without fetal images.
Ovarian flavinized cysts: Ovarian flavinized cysts are often present in some patients and may be detected by double colectomy or more easily by ultrasound.
Hemoptysis: Some patients may have hemoptysis or blood in the sputum, and the physician should ask for this symptom.
Anemia and infection: Repeated bleeding that is not treated in a timely manner will inevitably lead to anemia and related symptoms, and in some cases, even death due to bleeding. Repeated bleeding can easily lead to infections, such as unclean vaginal practices or sexual intercourse during bleeding.
The infection is more likely to occur if the vagina is not clean or if there is intercourse during bleeding. Infection can be confined to the uterus and adnexa and can lead to sepsis.
Clinical manifestations
1. Vaginal bleeding after menopause usually occurs 8 to 12 weeks after menopause, and some patients may have paroxysmal lower abdominal pain before vaginal bleeding.
2. Abnormal enlargement and softening of the uterus About 1/3 of patients with complete gravida have a uterus larger than the month of menopause and are accompanied by abnormally high serum HCG levels.
3, pregnancy vomiting occurs earlier than normal pregnancy, with heavy symptoms and long duration.
4, signs of pre-eclampsia eclampsia may appear before 20 weeks of gestation with hypertension, edema and proteinuria, and the symptoms are severe.
5, ovarian flavinized cysts are often bilateral, if torsion or rupture occurs, acute abdominal pain can occur, which can subside on its own after the clearance of the chylothorax.
6, abdominal pain caused by rapid growth of the gravida to overextend the uterus, manifested as lower abdominal paroxysmal pain. If the cyst is twisted or ruptured, acute abdominal pain can occur.
7, hyperthyroidism signs about 7% of patients can appear mild hyperthyroidism performance.
Pathology
The true pathogenesis of staphylococcal fetus is unknown. A case-control study found that the occurrence of staphyloma is related to nutritional status, socioeconomic and age. Age is a significant etiologic factor, with the incidence of staphylococytes being 10 times higher in women older than 40 years than in younger women, and age younger than 20 years is also a high risk factor for the development of complete staphylococytes, with women at both ages being prone to fertilization defects. Partial gravidity is not associated with maternal age.
Cytogenetic studies combined with pathological studies have demonstrated the genetic characteristics of each of the two types of staphylococytes. The chromosomal genome of the complete gravida is of paternal origin, i.e. the egg develops in the absence or inactivation of the oogenic nucleus and the spermatogonial nucleus. The karyotype is diploid, 90% of which are 46,XX, and is formed by fertilization of an empty egg (egg without genetic material) with a haploid sperm (23,X), which recovers by its own replication to a diploid (46,XX) and then grows and develops, called empty egg fertilization. A minority of karyotypes are 46,XY, which are two sperm with different sex chromosomes (23,X and 23,Y) fertilized at the same time, called double sperm fertilization. Partial gravida is often triploid in karyotype, with 80% being 69,XXY and the rest being 69,XXX or 69,XYY, from a normal egg fertilized with a double spermatozoon, which brings in an extra set of paternal chromosomal components; it can also result from a normal haploid egg (or sperm) united with a diploid gamete that has failed meiosis.
Pathological changes
1. To the naked eye, the lesion is confined to the uterine cavity and does not invade the myometrium. The placental villi are highly edematous and form transparent
The placental villi are highly edematous, forming transparent or translucent thin-walled blisters containing clear liquid, connected by a tip and resembling grapes. If all the villi are grape-like, it is called complete gravidity; if some of the villi are grape-like and some of the normal villi remain, with or without the fetus or its appendages, it is called incomplete or partial gravidity. The vast majority of staphs occur in the uterus, but individual cases can also occur in the area where the ectopic pregnancy is located outside the uterus.
2. Microscopically, staph has three characteristics.
(1) Enlargement of the villi due to high degree of interstitial edema.
(2) disappearance of blood vessels in the interstitium of the villi, or a small number of non-functional capillaries with no red blood cells inside are seen.
(3) Trophoblast cells are proliferated to varying degrees, including syncytiotrophoblast and cytotrophoblast cells, which are present in different proportions and are mildly heterogeneous. Trophoblast hyperplasia is the most important feature of staphyloma.
The cytotrophoblast cells are located in the inner layer of the normal villi and are cuboidal or polygonal in shape, with lightly stained cytoplasm, medium round nuclei and sparse chromatin. The syncytial trophoblast cells are located in the outer layer of the normal villi, with large and irregular cells, acidophilic dark red cytoplasm, multinucleated, and darkly stained nuclei. In normal villi, after 3 months of gestation, only syncytial trophoblast cells remain, whereas in gravida both types of cells persist and are actively proliferating, losing their normal arrangement and aggregating in multiple layers or in patches.
The pathogenesis of complete gravidity may be related to geographical, ethnic, nutritional, socioeconomic factors and gestational age. Those with dietary deficiencies of vitamin A and its precursor carotene and animal fats have a significantly higher chance of developing grapevines. Age is another high risk factor, with women older than 35 and 40 years of age having 2 and 7.5 times more incidences of staph in pregnancy than younger women, respectively. Conversely, the incidence of staphyloma is also significantly higher in women younger than 20 years of age. A history of previous pregnancies is also a high-risk factor, and the incidence of recurrent gravidity is 1% and 15% to 20% for those with one and two previous gravid pregnancies, respectively. The karyotype of complete gravida is 46XX in 90% of cases, which consists of an empty egg with missing or inactivated genetic material in the nucleus fertilized with a haploid sperm that replicates itself into a diploid. The other 10% have a karyotype of 46XY, resulting from the union of an empty egg with two haploid sperm (23X and 23Y) at fertilization. It is now believed that the solitary male origin of the complete gravida chromosome is the main cause of trophoblast overgrowth and may be associated with genomic imprinting disorders.
Partial staph, may be associated with the use of oral contraceptives and menstrual disorders. More than 90% are triploid, with an extra set of chromosomes usually from the father, fertilized by a normal haploid egg and two normal haploid sperm. Or they are fertilized by a normal haploid egg (sperm) and a diploid sperm (egg) that has failed meiosis. In both complete and partial gravida, excess paternal genetic material is the main cause of trophoblast hyperplasia. Very few partial gravidas have a tetraploid karyotype, but the mechanism of formation is not known.
Classification
Staphylococci are divided into two categories.
1. complete gravida: all placental villi are involved, there is no fetus or its appendages, and the uterine cavity is filled with blisters;
2. Partial gravida: only part of the placental villi are blistered and there are still living or dead embryos in the uterine cavity.
The above classification has been used for the past few decades. In the past, partial gravidity was also known as “transitional blistered mass”. Many people believe that partial gravidity is a manifestation of an intermediate process in which normal tissue develops into a full-blown gravidity. In fact, in recent years, the use of scientific techniques such as genetic evaluation and genetic analysis of the tissue has revealed that there is no “transition” between the two, but rather two different diseases.
1. Complete gravidity: It is an abnormal placenta with trophoblastic proliferation. There is no fetus or embryo.
2. Partial gravida: It consists of large villi and small villi that are scalloped (also called coastal) in shape, with trophoblast inclusion bodies and some may have mild trophoblast hyperplasia. There may be a fetus or embryo present.
Diagnostic differences
1. The presence of embryo or fetus is not the focus of the difference between the two, but it can be referred to. Complete staphyloma usually has no embryo or fetus. Partial gravida is usually seen as an embryo or fetus.
2. Proliferation of trophoblast cells. (One of the main diagnostic bases in pathology) Inside a complete staph, more severe trophoblastic hyperplasia can be seen. Moreover, these proliferations are larger in size and most of them are around the whole vesicle.
In partial staphyloma, relatively few trophoblastic hyperplasia are seen, and if they are, they are relatively mild and small in size, usually just a corner of the vesicle or part of it is hyperplastic.
3. Appearance. In the past, when diagnosing staphyloma, we used to look at the chorionic villi (i.e., vesicles) that had been degenerated and edematous. In fact, this kind of villi plays an important diagnostic role in the diagnosis of complete and partial gravidity. In complete staphyloma, the vesicles are rounded and the outer layer is mostly surrounded by trophoblastic proliferation. In partial staphyloma, the vesicles are scallop-shaped (some call them coastal, wavy, serrated, or polygonal) and generally have no, or little, trophoblastic proliferation in the outer layer. Moreover, most of these vesicles are found to have small spines around the periphery of the partial vesicles, similar to those of cacti. It turns out that the classification of complete and partial vesicles is actually incorrect.
Complications
1. Staphylococcal haemorrhage
If the gravida is not diagnosed and treated in time, recurrent bleeding and blood accumulation in the uterine cavity may occur, resulting in blood loss, or heavy bleeding may occur during natural expulsion. On the basis of anemia, hemorrhagic shock and even death may occur. Therefore, gravida should be treated as an emergency, and short-term delay may cause more blood loss and endanger the patient.
2. Incomplete miscarriage of gravida
After spontaneous abortion or aspiration abortion, there may be residual blister-like fetal mass. Those who do not have long spontaneous abortions before admission to the hospital for gravida patients and who can bear the clearance operation should be cleared immediately. For those who have been expelled for a long time and have signs of infection, the uterus should be cleared after applying antibiotic control for several days.
3.Staphylococcal embolism
Blistered fetal masses may metastasize or travel with blood transport to other parts of the body, most commonly the lungs and vagina, and may form local foci of hemorrhage. Small amounts of emboli or without close examination may subside on their own. Yu Pei-Liang et al. reported a case of extensive pulmonary metastasis from staphylococcus due to induction of labor with oxytocin, which resulted in pulmonary small artery healing syndrome and death from pulmonary edema and heart failure. Staphylococcal embolism can be different from malignant metastasis, which can be suppressed by autoimmunity and disappear. It has been reported by Qiaozhi Lin and Yingkuan Su. At present, chemotherapy is still the best treatment after detection.
4.Malignant change Become erosive staphyloma or choriocarcinoma. The rate of malignant transformation is about 10%-20%. For details, please refer to the following.
5. Ovarian flavinized cyst torsion Most often occurs after the gravida is expelled. In case of torsion, the cyst should be extracted under ultrasound guidance first, and most of them reset naturally. The torsion is prolonged before surgical removal of the torsional uterine adnexa is required.
Clinicopathologic association: Patients most often present with symptoms in the fourth or fifth month of pregnancy, due to placental chorionic edema resulting in a significant increase in uterine volume beyond the normal uterine volume of the corresponding month of pregnancy. Due to early embryonic death, the fetal heartbeat is not heard and there is no fetal movement, although the uterine volume exceeds the normal 5 months of gestation. As a result of trophoblast proliferation, the patient has a marked increase in chorionic gonadotropin HCG in blood and urine, which is an important indicator to assist in the diagnosis. The trophoblast cells are very capable of invading the blood vessels, so the uterus bleeds repeatedly and irregularly, with occasional grape-like discharge. If gravidity is suspected, the diagnosis can be confirmed by ultrasonography in most patients. The majority of patients can be cured after complete removal of the uterus. About 10% of patients can be transformed into erosive staphyloma, and about 2.5% can be malignant to chorioepithelial carcinoma. Because of the potential for malignant transformation, hysterectomy may be considered if the patient does not need to have children again. Embryos with partial gravidity usually die in the 10th week of gestation, and some of the embryonic components can be found in the aborted or scraped tissue.
Clinical diagnosis
The general diagnosis is amenorrhea, with vaginal bleeding occurring in most cases at two or three months of amenorrhea, or even later. The bleeding can be more or less frequent and intermittent, and in most cases it is possible that the uterus is larger than the month of menopause. When the uterus reaches four or five months of gestation, not only can the pregnant woman not feel the fetal movement, she cannot touch the fetal mass and cannot hear the fetal heartbeat. The diagnosis is confirmed by a careful examination of the vaginal bleeding, which reveals a blistering fetal mass, and an ultrasound abdominal scan, which may reveal dark areas of varying size in the uterus, due to the accumulation of blood in the uterine cavity. It also reveals the fetus, i.e., in addition to the snowflake light film, there may be images of the fetus and/or placenta. hCG measurement: The accurate quantitative test of hCG is an important test for the diagnosis and follow-up of staph. hCG is low at the beginning of a normal pregnancy and peaks at 8-10 weeks of gestation and then gradually decreases. After the gestational week (100 days), hCG decreases significantly. In twin (multiple) pregnancies, the amount of hCG is also higher than in singleton pregnancies. In chylothorax hCG levels are much higher than normal and remain high.